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HomeMy WebLinkAbout0010 WEST WAY - Health 10 West Way Centerville A= 246- 163 -001 UPC 12534� � I rr���� No. C7'ti�,s ._,Cj Jr' L) ,�" r Fee /Q THE COMM LTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, M'ASSACHUSETTS ZIpplicatton for Miopooar *pgtem Cottgtruction Permit Application for a Permit to Construct( , )Repair( )Upgrade( Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. ,s ner's NaJme,Address and Tel.No. /ar Xl/ s> (�/,gX CP r�► �/Pam'' Assessor's Map/Parcel Installer's Name,Address,and Te.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other 'Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design.Flow gallons per day. Calculated daily flow gallons. Plan Date_ Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)/9 S '� /�i 13,�P l h'�''e e' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with,the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance h i of He ign a Date Y Application Approve Date Application Disapproved for the following reasons Permit No. o�� —� Date Issued 4 ,6 y " aT L A Pv' D No 6 5 -) may:, m. ':,:+' Fee r• " �. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes - PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYtcation for 30igpoga1 *p!tem Conotructton Permit Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Te.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) . Other Fixtures Design.Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date f Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)/Q 1-3S'7- A/ f oG Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance ha �e- 'ssued h is, oard of Healt'!'�` _ Signed ' - Date, � � S Application Approved Date C9�- IO Application Disapproved for the following reasons Permit No. Date Issued / g- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed Repaired Upgraded ( ) Abandoned( )by at O 64-" /= S 7- LL% has.been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. / dated Installer_ 2 Designee,C2 "O"Y 1,-7,5F yam' The issuance o s .'ermit shall not be construed as a guarantee that the system will function as designed. Date 'C Inspector No d�5 �.5 I —®----------------------Fee Q 16 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwte;pozal *pgtem Congtructton Permit Permission is hereby granted to Construct( )Repair( )Upgrade(,,�)Abandon( ) System located at O Gt/E S and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with.Title 5 and the following local provisions or special conditions. Provided: Constructil�must be completed within three years of the da a of�,i°t. Date:_ .J Approved h TOWN OF BARNSTABLE LOCATION /� w (/�/ �'' SE'VAGE VILLAGE ASSESSOR'S MAP & LOTZ4 6� DO 1 INSTALLER'S N AS e-N G z SEPTIC TANK CAPACITY LEACHING FACILITY: (type(J—)Ja s-6, ALE) 7<A,7Ll%ize) NO.OF BEDROOMS 7 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the:. Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by LO-I�o is rws i 33 , 30 BD = 3- ' TOWN OF BARN$TABLE LOCATION Y SEWAGE #Q 06 VILLAGE Y!} �r/rL�'/ ✓�G C;Z ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. e-k 7 75 SEPTIC TANK CAPACITY _ LEACHING FACILITY:.(type_..3 ) NO.OF BEDROOMS _ BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within`200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i /t 0 r 0 0 (Sw-s i C tA0,P=02.q,5'� _,0 Town of BArnstable --1�3- 06-1 �OpfHE ram, 'R.egulatary Services . Thomas F. Geiler,Director MAW. Public Health Division i63'9' rEp�hpca Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 r Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 3 3, Designer: ,�g�� a✓ tyE Installer:/,�A.G-/ S'i Address: PO. 191 Address: lea ,X' 5/::z E SAAd w►cr,, � OZ537 LAA-,1 On was issued a permit to install.a (date) (installer) septic system at l B s y based on a design drawn by (address) / RA ,C A," E Y Z /L dated ,;- �/ J L (designer) XI certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State& Local Regu Plan re Sion or certified as-built by designer to follow. OF — s R rs -YCR Cn Signature) �NGoI. 114�0 S 71s n TESANITAR\P� 0 �V� (Designer's Signature) (Affix Designer's Stamp Here)_ PLEASE RETURN TO BARN ABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOT111 THIS FORM' AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE WiTuir IC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form I FA' JED INSPECTION 51z (011) RECLE: E- COMMONWEALTH,OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AF NOV 2004 TOWN OF BARNSTABLE DEPARTMENT OF ENVIRONMENTAL PROTECTIO`N�EPr. PARCEL, .� I- VS 66,�� TITLE 5 - �I - OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 10 West Wav 2 Sxtems West H annis ort MA 02672 Owner's Name: Jo&Bill Cleary Owner's Address: 27 Kinzwood Road Auburndale, MA 02466 Date of Inspection: November 12 2004 Name of Inspector: (Please Print) James M. Ford Company Name: James M.Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes (Title V system) Conditionally Passes Needs Further Evaluation by the Local Approving Authority ✓ Fails (Single cesspool) Inspector's Signature: Date: November 1.5 2004 The system inspector shall sub it a copy, of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 West Way West Hvannisport MA Owner: Jo&Bill Cleary Date of Inspection: November 12, 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in-3 10 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND'explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 West Wav West Hvannisnort MA Owner: Jo&Bill Cleary Date of Inspection: November 12 2004 C. . Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 West Wav West Hyannisnort MA Owner: Jo&Bill Cleary Date of Inspection: November 12 2004 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped— ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. NOTE. SINGLE CESSPOOLSAUTOMATICALLY FAIL IN THE TOWN OF BARNSTABLE. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10 West Way West Hyannisport MA Owner: Jo&Bill Cleary Date of Inspection: November 12, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ — Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ _ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _ 10 West Way _ West Hvannisport MA Owner: Jo&Bill Cleary Date of Inspection: November 12 2004 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): n1a Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n1a Is laundry on a separate sewage system(yes or no): n1a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): Pumping Records GENERAL INFORMATION Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system ✓ Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: The Title V was installed in 1989-Der as built card. The sin le cesspool was on final. Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 West Way West Hvannisnort MA Owner: _ Jo&Bill Cleary Date of Inspection: November 12 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Me urinz stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet covert,evidence of leakage,etc.): Cement tees were present The hauid level was even with the outlet invert There did not appear to be any signs of leakage GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 West Way West Hvannisnort MA Owner: Jo&Bill Cleary Date of Inspection: November 12, 2004 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: -gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level. No solids were Dresent. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 a I " Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 West Way West H annis ort MA Owner: Jo&Bill Cleary Date of Inspection: November 12, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: _I-6'x 6'(1000gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The leach pit was drv. The scum line was 6"up from the bottom There did not appear to be any sig'_ns offailure The bottom to jzrade was 9. The cover was 32"below zrade. CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: I-single Depth-top of liquid to inlet invert: Depth of solids layer: -- Depth of scum layer: -- Dimensions of cesspool:_S'W x S'T x T bottom to grade Materials of construction: Cesspool block Indication of groundwater inflow(yes or no): None Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): The cesspool was dry with 10"ofsludQe on the bottom The cover was 18"below grade Single cesspools automatically Earl in the Town ofBarnstable. PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 s Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 West Way West Hvannisnort MA Owner: Jo&Bill Cleary Date of Inspection: November 12 2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. t-��J,5 --------- cm O $i W B 3 18 � a O O 51 3 aye i� ° y 3C ay 10 v Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 West Way West H annis ort MA Owner: Jo&Bill Cleary Date of Inspection: November 12 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 18+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours mans Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the maps were showing approximately site. 18'+/ to Around water at this This report has been prepared and the system inspected and passed/failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,relating to the system, the inspection and/or this report. 11 _ TOWN OF BARNSTABLE LOCATION `10 Wtrr Wf31 SEWAGE # VILLAGE W• H" ifa/1nupo l� ASSESS@R,', INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY QTO / s/i►S� a4.0LO' LEACHING FACILITY: (type) L)<(* P, 1 (size) RUIN NO.OF BEDROOMS BUILDER OR OWNER CICA PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachi g facility) Feet Furnished by �rlS/�c07,0^ r re" Alf O �I hie /7 O O i8 O Oak ST(u-r �� �✓ 0� 1 9A� el � � Fps THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..........................................OF.......................................----------....._.......-----•--------.............. Applirttiion for Uhipasal lVorkii Tonsirurtiun thrutit Application is hereby made for a Permit to Construct ( or Repair ) an Individual Sewage Disposal System at: � — l .C � .. r9 ................................... _..._.... ......... Lo ion•Address t No. �?� ............... .._....-••............... ................................................................. W �� Owner V Address ��/. V..._..Ate, .7�--••-----------•-----------------------• --._....................................................................... Installer Address Type of Building Size Lot............................Sq. feet Dwelling=No. of Bedrooms.......... __------------------------------Expansion Attic ( ) Garbage Grinder ( ) Pk Other—Type of Building ____________________________ No. of persons____________________________ Showers ( ) — Cafeteria ( ) a Other fixtures ........................-----------•------------•-•----------------------•------------- -•--------------------------------.._..---------------------- W Design Flow............................................gallons per person per day. Total daily flow_.._..._.______________.______._...._.._____gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter-_._-__.________ Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1________________minutes per inch Depth of Test Pit___________.________ Depth to ground water........................ r= Test Pit No. 2........._......minutes per inch Depth of Test Pit...............``:_. Depth to ground water........................ Ix ---•-----•---__._---•---•----•-----•--•------------•--•----------------------•-__-----------•-•_._.......................................................... 0 `'Description of Soil_____________________________ x U -------------------------------------------------------••------•---._...__..._._____-----•--•---...------------•••----------___.-------•---•---•----................................................... x - --------------- - U Nature of Repairs or Alterations—Answer when applicable___...__.._1A,11_. „i�______________________________ --------•--------------------------•--•-••-•••--•--•---••-•--•••••--••••••••-------._......-•-••-•-•-•----•-------------•--••__----______----•------___...__._.___..__._______._____.__._•_••••-•____-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code.— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed....................................................................................... ................................ Date Application Approved By........ ...................................... -..-.� -^._$_ _._.__..._ -- Date Application Disapproved for the following reasons:.....................................................................................•--........................ ............................-........................................................................................................................................................................... Date PermitNo. _ "...-. _• ......_-•-------- Issued.-•----•-------------------••---•--•---------•--••••--- Date No........F q., .1 FEB.. c ......--r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... ...............................:O F................................. ....... Applirtttiun for Dispasal Workg Tonstrur#inn 11nmi# Application is hereby made for a Permit to Construct ( ) er-R-epa�r j( j an Individual Sewage Disposal System at: ---- � ........................... ..•---•--------------- ----------- .------. ---• -------• ----- Location-Addre s WG� X of o t (Lot No. W Owner ress�. Ac�'d /..... . >i.YT ------------------------------- Instal er Address - Type of Building Size Lot............................Sq. feet ►-, Dwelling—No. of Bedrooms...........�4..............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 94 x Septic Tank—Liquid'capacity..._........gallons Length................ Width---------------- Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY..................................................................... .... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water----_----_------_-___--. �1;4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ,:4 --.-----•--••---•-•-•--•••-•...................•••....--•...•--•--•.....-•--•-•----•---......- 0 x -Description of Soil----•-------------------•---....-•------------...---------...•.....----------------------------------- -•---•----•-----•-•--••••••••----------•---•---•-•-•-•--••-•... U --•--•-•-•-••--------•--------••••---•-.....•---•---•-•-•--••------•--••-------•-•-------------•-•--•-•---•--•--------------------•-•-•--------•---•----•----•------•----------••---•---•-••----•-...... VW ••-•••----------------------•--••--•---•••-•--•-•••-----------•-•-----•-•••--------•--•---•----•---•----•------•-'-------------------- ----- -�,-�}-� ..a Nature of Repairs or Alterations—Answer when applicable---___-- --- ---------- ------ L�(.f ----- 5................................ •-•-•---••••--•--•-••••-••--.....-----•....•---•-•-••••--•-••--•---•--•-•------••-•-.....--•---......•-•--•••-•--------•----•----•------•••-•-•-•••----•••-•-----•--•-•-•-••...................•--••-•-- Agreement: The undersigned agrees to install the aforedescribed' Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The,u rider signed further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... Date ApplicationApproved By..... -----•--•-----------\--------..............------------------------...------------------ .................. ------------•- �j .2 _ Date Application Disapproved for th ollowi' reasons ------------------------------------------------------------. --- -t/- .Sr. !......... ........... ----------------------------------------- ---------------------------------------------- •---------------:------------------------------------------------------------------------- Date PermitNo. . --... .. Issued...................................•---•-••--•-•---•--- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........IE�1*11*11111*11*1­­1111 OF.............. ... irtt#ie ,&nrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY................ . ...... - .-....................................Installer-•••-••--•---•------••-........---•--............•-------.......------....-•------•-•---_..._ �. Installer at.......... n ..,� has been �n�alled�ii'a�nce (Od rovisions of T"! 1E 5 of The State Sanitary Code as described in the application for Disposal Works Construe ion Permit No......................................... da.ted_..-------.........___....................... THE ISSUANCE OF THIS CERTIFICATE SHALL I►F&EiftRSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.....-••--•------•--------..J5_..._rtG. ........................ Inspector............... ,Z................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............................OF................................: ..................................._............ -- .. N .��_�•,�}� �C�C.wi. � r� .�'.��-r FEE........................ Dispulitt1 nrku �unirinn lerntii Permission is hereby granted.....- •--•-�.}�---------•. -----------------------•-------------------•-----------------•••--•----•......_.... to Construct ( ) or Repair ( ) Ifid ldua1 � a Disposal System atNo.......... .k....... .................Ens, ........:.._......... -• ... -..._.. ----------------------------------------------------- Pe I I Strr izc..,o �.}� as shown on the application for Disposal orksruc on mit I�..----_._..":._____. Dated.......................................... ............................�.`��' .............................................................. DATE. Board of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS TOWN OF B AISLE LOCATION f SEWAGE # 99-oZOq VILLAGE`VAC it _ l" ASSESSOR'S MAP� LOTo 4'/b3'001 INSTALLER'S NAME & PHONE NO.�Zh'0 '4\- SEPTIC TANK CAPACITY LEACHING FACILITY:(type) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC: WATER_ BUILDER OR OWNER_ DATE PERMIT ISSUED: , DATE COUP LIANCE ISSUED: VARIANCE GRANTED: Yes No /�/ f ;j' / � ✓ �� /mil +�I / � ��� fib! ��'�� �. ,�`� ✓� r . r r� j�l AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION /0 w ^ST AlAY SEWAGE 4 k 1 ILLS VII.LAGE ((,,�� ASSESSOR'S & INSTALLER'S N dtP�_ Al- e-N SEPTIC TANK CAPACITY r LEACHING FACILITY: (type 01�/F/ 7 2.�a7Dize) -40.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) _ Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Furnished by C D 02 rs-vvs i 0P a A �l, ,y � ai35r4vrton� ��2i /)P=' 30 / http://issgl2/intranet/propdata/prebuilt.aspx?mappar=246163001&seq=1 8/30/2010 rn•. Ny Z rnm 0 ( CONT.RIDGE VENTIb W Q Z m a 10 RGe 30. V cOLLARnES®IG-O.C. J { O W O d4 0� Z rc 2%8 RAFTERS®16'O.C. 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(VERFY EN_zE) O PROP05ED WDW WELL p ;f (VeRFY 512E) I t1b OL (3)2%1 O RM BOARDS SOUP 6XQ POTS BTW4J. I I (3)2X O RM AROUIJD PERIMETER - -_-____ I r2 o J l DTOO OSRO/Nw�B¢.9-U-T(r,1.T)'.) I n METING 6 • U15TNG UNFINI5NED ABUGG �5T bA5E5 EONOTU515 BEHJND OFFIC BASEMENT OrU (NGFDOT AT 51D5 ONLY) , L J I ;z G'-10'CEILING tT. _ 2'-3 1/2O ... 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IPrm .�.. �� FLOOD ZONE: �D f l 1k klA g 3 T a R THIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF � WITNESS:7NES S: $A'R 5T�}> Lg BOARD OF HEALTH REGULATIONS.�, u ��t�Itit� L P,o O �T I� ' �� DATE: f , REFERENCE: Z-�g ' 2) .THE . INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO PERCOLATION RAT : (L�"15 _ INSTALLATION. t � 11 st N TH- I OL-2�10 TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION .04 D ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE y v qua A LoAml (o ay DETERMINATION. SPrNb 1 7. ��Nof p'�2-" 4) ALL PIPING TO BE 4" SCHEDULE 40 (a; 1/8 "l FOOT. (UNLESS q / SPECIFIED OTHERWISE) .. x.. o� D R E G� rl LO ,p s�c*1 LOCATION MAP t-{ rs) EVER ,�-� S) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A No. 1140 "+ GARBAGE DISPOSAL. `�� I; o►STE�a 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) F b� S�-��' , SANITARY* C MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON 2 6 � A BASE OF 6"OF CRUSHED STONE. 7 EVST7 ces5A00L V PvE-PvmPWA CV-50€IP '�_ l32 -13. a rto tn► r*%f.uEv g• uo>n rtS s_. ►N REML of,,P><to - 70 "_tea- SEPTIC SYSTEM DESIGN ►wA wt, inlh: oF __1 +t�n► 10• Ajo lNE7L49NQf w , I501OF P"P FLOW ESTIMATE -EX1ST1 N +$R. Utz-Et.l.td 4 06 mizi cE5 V ot, 7ovviv orn &MS- :� BEDIOOMS AT 110 GAL/DAY/BEDROOM 8,30 GAL/DAY 'E�D. 0 F 1�,fl1.T>�4- T�EG ZJr�i._aTlS � ` - D016N Fit. S AP- (ipr 4'1 Y SEPTIC TANK 25��8 C�(1517� ----- SF�IPTIC. LGA:./DAY x 2 DAYS - GAL St.,bTE1� USE GALLON SEPT I C TANK SOIL ABSORPTION SYSTEM 22 1 - oe fN Fl LT ZAib,_ 30 So UN i i s „L3.9 SPN>E oA) SIDE AREA:E(30)2.+ to-)Z] c2-k 0,7y = 1 . o \ \ BOTTOM AREA: 130 jr 10` x O•?Y = 2-2 2.. q 340.6 6P >33o 4iob rel Q! SEPTIC SYSTEM SECTION a� Tad` EL.Z'S.13 .. { FIL' Z,5.S'o Zcry 10 ) 1 oecs s To W/„' I �s N+ ¢�, G '►,; h dam ) t 3(o M�3�C vi ti �r A EL. 22 Sb 12l w Io 1 JI^' i P .�. thsfgil 26 _ _ _T.s�• �,�,iS ` I� ��E D ` 8n4t# t.o? Zz. 15 ZZ.�j;j , GAL / D-BOX�, \ 70 SEPT I C TANK CROss SEC77OA/ C�✓Ts- ;lf`'- 7ES' ?Wz.F_ EL 13.70 114Y ZM-�`8� u1 ;j ` e SITE AND SEWAGE PLAN TaM WAle 3 y : " vb� LOCATION : ! W Cl� E IL 27.$ �� -dL Oso 'momw4ske-4 ofN/vu o�c r- 3s� PREPARED FOR : f#' Ght Cowsrl"c.7-tDA) SCALE:, DARREN M. MEYER, R.S. DATE: 2 7 a1' P.O. BOX 981 -- EAST SANDWICH, MA 02537 DATE HEALTH AGENT Ph: (508) 362-2922 W 3 2